Incivility hurts

By Dr Ellen Meyns

Dr Ellen Meyns, FACEM

A new day at work. A new term. A new clinical year. The department is buzzing with the nervous energy of a batch of fresh young doctors: introductions, name badges, talks, tours, expectations. First cannula, first morphine order, first plaster, first discharge summary. Proud people will go home tonight and tell their loved ones about being a real doctor, at last.

I’m enjoying myself. I work hard to make sure everyone feels supported, and the newness in the air helps me reflect on why I love Emergency Medicine. I feel switched on and curious. During the shift, I untangle a tricky diagnostic dilemma and explain my reasoning to my patient, her family and the junior doctors. I feel satisfied with myself. A lot goes on around me, but I feel connected. I feel good. I feel safe.

But then – one interaction breaks the mood. A senior inpatient colleague openly challenges my diagnosis – ‘It’s so obvious that it is nothing serious – send the patient home’. I feel ashamed and belittled. Around me, jaws drop – the bystanders, including our medical newbies and the patient’s family, also feel my hurt and shame. My colleague has dismissed my diagnosis without even laying hands or eyes on the patient. She simply does not trust my clinical assessment. She does not believe a word of my handover.

Incivility and disrespect are frequent visitors to my practice as an Emergency Physician. It can feel like the rest of the hospital treats my ED colleagues and me as naughty toddlers. ED can be seen as ‘such a hassle’, just moving patients for the sake of it, generating work for the other teams. Only a few days ago, another department’s director openly declared that Emergency Medicine is the least respected specialty in the hospital (yes, really!). It seems culturally acceptable to give ED clinicians a hard time.

Prof Vic Brazil brought the idea of civility to the forefront with her tribalism talk (https://vimeo.com/95243749) at SMACC 2014. Patients and clinicians are harmed when we treat each other like we are each other’s opponents – competing tribes, as it were. Ultimately, we all want the same outcome though: connection, and good patient care. So why not collaborate in a respectful fashion?

I think of myself as a tribe leader these days. And I openly advocate for peace amongst and between tribes. But equally, I will speak up when one of my tribe is harmed.

Why does incivility hurt?

Incivility in hospitals is dangerous – for patients and for staff. There is evidence that victims, and witnesses, of rudeness become cognitively overloaded, with negative effects on their ability to make effective decisions (1). Incivility in the workplace is also a major trigger for professional burn-out (2).

Contributors to incivility – demand and system issues

There were 8,017,492 presentations to Australian Emergency Departments in the 2017-18 financial year! With this, patients are more complex and undifferentiated, patient expectations have changed, we over-investigate a lot of pathology in the acute phase, and specialties have become narrower in their level of expertise. Everyone is overworked and the system is stretched.

Patient flow is a whole-of-hospital problem, yet ED is almost always seen as the main culprit for hospitals failing to meet KPIs. Senior ED clinicians should be able to move patients where they need to go for appropriate care, in order to continue to provide timely and quality care for all patients. ED is the only department in the hospital that can’t say ‘no’ and has to keep functioning regardless of resources, space, overcrowding and chaos.

Sadly, protests about consults or admissions in the ED often come hand-in-hand with incivility and bad behaviour.

Please don’t take your frustration out on each other – we’re all in this together. We need to be allies. We’re collectively advocating for change across the whole system.

Consequences of incivility – individual

Incivility is different from aggression as it usually lacks the intent to hurt. However, open lack of respect for colleagues, junior or senior, results in psychological harm.

After the diagnosis I made was challenged, and my initial anger diffused, I felt deflated for hours. No matter how senior, how tough, or how resilient the clinician, humiliation and lack of empathy damage a clinician’s sense of self-worth. Repeated exposure to this type of behaviour results in stress, anxiety, depression and emotional burn-out. It contributes to clinician suicide. (On this note, Dr Tessa Davis wrote a great blog on strategies on how to deal with rudeness: Davis, T. On Rudeness, Don’t Forget the Bubbles, 2018)

Rudeness is dehumanising. All medical practitioners start out in the profession for the patients – to help people. Yet when immersed in hospital culture which does not prohibit incivility and aggression, we lose empathy for those we care for – our patient becomes ‘the appendix in bed 6’. We need to respect each other to maintain respect for our patients and provide compassionate care – the sort of care we would want for our own families and friends.

Consequences of incivility – the ‘incivility spiral’

Bad behaviour is modelled to the entire team including junior doctors and medical students. It becomes the cultural norm. Andersson and Pearson (1999) called this the ‘incivility spiral’: uncivil behaviour permeates the work environment and becomes a defining characteristic of the climate. The result is a generally high-stress dynamic that is experienced throughout the workgroup, even by members who are not directly subjected to the disrespectful treatment. This may even extend to the organizational level. The witness of a violent event becomes a co-victim and suffers adverse effects, because the indirect exposure alone is a traumatic experience. Furthermore, such situations may invoke empathy for the plight of the victim. Awareness of in-group members’ mistreatment could also arouse feelings of injustice, fear, or frustration, fuelling further negative attitudes. Subsequent generations are constantly exposed to rudeness, having adopted angry and harmful behaviours themselves.

You can’t be what you can’t see – and you will tend to be what you can see – so please be kind and caring, and deliberately role-model good behaviour and effective interpersonal communication to your junior colleagues.

Consequences of incivility – team

Incivility also negatively impacts on medical team performance. A study from the simulation literature (Riskin et al) examined the effect of rude team members on patient outcomes in neonatal resuscitation and found that bad behaviour led to poorer diagnostic and procedural performance. The evidence demonstrates that good behaviour is a no-brainer – it leads to better patient care. I never feel at the top of my game around a rude colleague. Do you?

My message is simple. Civility is good for everyone – for you, for me, for our colleagues, and for our patients. Empathy is the key to meaningful connections, and to personal and professional growth. Please open your heart to others: be kind; be compassionate; be curious.

If you do transgress, because you’re tired, stressed or hungry, then just apologise.

If you think someone (including me) has made an error, please tell them respectfully.

If you think you are burned-out, or if you’re struggling even a little, then please speak to a friend, a supervisor or your GP. And know that if you have nowhere else to turn, I’m willing to listen and support you, as will many of my colleagues.

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2 thoughts on “Incivility hurts”

Thank you for taking the time to write this post. I have always liked the quote by Sharon Salzberg “few people are powerful enough, persuasive, persistent, consistent, and charismatic enough to change the world all at once, but everyone has the ability to affect the three feet around them by behaving more ethically, honestly, and compassionately toward those they meet.
Great article. I will be referring to it in the future.

I particularly liked that you highlighted the effects this can have on even a seasoned clinician, the fact that it happens to all clinicians regardless of seniority, and some suggestions for how to manage as the transgressed (and the transgressor).

Once the acute transgressed/transgressor phase is over, the WellMD approach to workplace wellbeing (https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/) can be a useful framework with which to approach this and other workplace wellbeing matters. Focusing on the each of workplace “efficiency”, workplace culture of wellness, and personal resilience hopefully will ensure positive actions are taken to reduce the frequency and adverse effects of incivility.